A gonadotropin cycle begins with a baseline ultrasound, which is an ultrasound done during your period to make sure that you do not have any ovarian cysts.
A gonadotropin cycle consists of injectable medications to make several follicles (eggs) grow, a trigger injection to cause ovulation to happen, and then intrauterine insemination (IUI) to deliver the sperm to the egg. The injectable gonadotropins are much more powerful than the oral fertility medications (Clomiphene or letrozole). For this reason, careful monitoring must be performed to reduce the risk of both multiple gestation and ovarian hyperstimulation syndrome. We pride ourselves on providing best in class patient education, so prior to starting a gonadotropin cycle, you will be given materials to read, videos to watch, and a personalized injection lesson taught by one of our clinical staff. You will also review your proposed treatment cycle with your clinical nurse and your physician. In addition to answering your questions and making sure that you are prepared to proceed, these sessions are designed to make sure that you will be able to give these medications to yourself at home. In the event that you are uncomfortable with giving yourself injections, we can arrange to teach your partner or a friend.
When you are ready to begin a gonadotropin cycle, we will ask you to call with the onset of your period. You will then be scheduled for a “baseline ultrasound”, which will be done on cycle day 1, 2 or 3. (Cycle day 1 is the first day of full flow) The ultrasound is performed to make sure that you do not have any cysts present in your ovaries, as cysts can be hormonally active and, due to their size, can prevent or limit the development of ovarian follicles. They might also be stimulated by the gonadotropins and grow in response to your injections, leading to pain and a suboptimal response. If the baseline ultrasound is normal, you will start the injectable medication on cycle day 2 or 3.
Gonadotropins must be monitored closely
While you are taking gonadotropins, you will need to be monitored closely with regularly scheduled vaginal ultrasound examinations and by blood estrogen levels. These procedures will be performed every two to three days while you are using the medications. The ultrasound exams and estrogen levels allow your physician to determine the optimal dose of medication to give you each day, in order to maximize your chance for pregnancy while minimizing your risk of multiple gestation. Although your follicles will grow significantly under the influence of the gonadotropins, unlike in a natural cycle, they will typically not ovulate on their own. Therefore, when your follicles are mature (typically 19 to 20 mm in average diameter), a trigger injection called Ovidrel® will be prescribed to you. This medication causes the egg(s) to ovulate (ie. released by the ovary) approximately 36 to 44 hours after the Ovidre®l shot is given.
Our research was integral in changing the way that gonadotropin/IUI cycles are performed.
Gonadotropins have been used as a treatment for infertility since the 1970s. From that time through the early 1990s, a single IUI would be performed approximately 36 hours after the hCG trigger shot was administered. We published a prospective, randomized study in 1992 showing that two IUIs (performed on the two consecutive days following the Ovidrel injection) produced significantly higher pregnancy rates than a single IUI performed 36 hours following Ovidrel. The rationale behind our study was simple: women do not ovulate at a precise time following an Ovidrel injection. To the contrary, ovulation occurs over a range of several hours. In addition, sperm must undergo several different biochemical processes prior to being able to fertilize an egg. Sperm can live inside the female reproductive tract for a couple of days and the egg is fertilizable for around 24 hours. Therefore, it made more sense to us to inject sperm into the uterus both before and after ovulation – significantly increasing the time interval during which motile sperm would be in the reproductive tract waiting for the egg to arrive.
Collection of the sperm specimen to be used for insemination can be done in our office, or at home if necessary. As it takes approximately 90 minutes for our andrologists to prepare the specimen after it arrives in the laboratory, it is very important to either collect or drop off your specimen at your appointed time. The specimen will be delivered to the TFC-San Antonio office as soon as it is ready, so that the IUI can be performed.
Inseminations are typically no more uncomfortable than a pap smear. They take approximately 30-60 seconds to perform and we will then ask you to lay still for about 10 minutes before you return to work or home.
Progesterone supplementation is typically prescribed after insemination.
Each monitoring appointment will take around 15-20 minutes. They will occur every 2-3 days for the entire time that you take gonadotropins (typically 8-12 days). Following your second insemination, while you are waiting to check your pregnancy test, we will ask you to take another medication called progesterone. This medication is typically taken vaginally, and we prescribe it because it has been shown to increase pregnancy rates. If you are pregnant, you will continue to take the progesterone until approximately 8-10 weeks of gestation.